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Rhabdomyolysis and myonecrosis: this is especially likely in the case of sea snakebites acne in early pregnancy purchase curatane 5mg with visa. Myoglobinuric nephropathy can be prevented by infusing mannitol 25 grams acne and menopause discount 40mg curatane visa, and sodium bicarbonate 100 mEq in 1 litre 5% dextrose skin care help curatane 20mg sale, over a period of 4 hours. Do wear shoes (or preferably leather boots and long trousers) when walking outdoors amid thick undergrowth or long grass. Do take care when collecting firewood, or moving logs, rocks, boxes, or debris which are likely hiding places for a snake. Do take care when climbing rocks or trees with dense foliage, or swimming in lakes or rivers with lots of weeds. Do use repellants in basements, attics and storerooms to ward off rodents and snakes. You may wake up with a venomous snake lying cosily next to you, attracted by your body warmth. Forensic Issues in Snakebite Snakes have been venerated and worshipped in India (especially by the aboriginal and Dravidian races) since ages. The mysterious power of inflicting death possessed by venomous snakes, their slithering movement, and periodic shedding of skin, inspired awe and dread among people of ancient civilisations, and led to their worship in idol form. On Nag Panchami day (as per the Hindu calendar), milk is offered to cobras as a form of propitiation. Also, there is a popular belief that he who kills a cobra will be cursed for generations. Almost all cases of snakebite reported from around the world are accidental in origin, and the vast majority are due to inadvertent or deliberate provocation of a snake by a human. Several occupations are associated with increased risk of snakebite: grass-cutting, working in rubber, coconut, areca nut, and tea and coffee plantations. While homicides can be accomplished by using a venomous snake as a tool, actual instances of murder committed by such an exotic method are rare. Deaths due to snakebite are regarded as medicolegal in nature, and a forensic autopsy is mandatory. Unfortunately, clear-cut signs of envenomation may be lacking in such cases, and even fang marks may not always be discernible. The common stinging hymenopterids include bees, wasps, yellow jackets, hornets, and fire ants. The term "hymenoptera" refers to membranous wings that characterise these insects. Epidemiology While snakebites are more common in tropical countries such as India, anaphylactic reaction to hymenoptera stings are much more common in temperate countries. The body of a bee is generally bright yellow with black triangular markings on the abdomen. Queen wasps have similar markings; however, they are larger and can grow up to 20 mm. Bees inject approximately 50 mcg of venom which is the total capacity of the venom sac, and leave behind the stings embedded in the skin, while wasps and hornets are capable of repeated stings. Ants generally bite firmly with their jaws and then sting or spray locally irritating venom. In individuals not allergic to the venom, a single sting usually produces only mild effects such as local pain, redness, irritation, itching, and swelling, which resolve in a few hours. These reactions are not IgE-mediated, but represent a response to toxic and inflammatory venom components such as vasoactive amines and peptides. Local reaction becomes dangerous only if the site of the sting is in a vital location. External eye stings can cause pain, swelling, lacrimation, hyperaemia, and conjunctival chemosis. Corneal stings can cause corneal oedema, ulceration, hyperaemia, pain, scarring, and linear keratitis. Severe cutaneous infection and cellulitis have occurred after stings from yellow jackets and wasps, which may pick up virulent bacteria while foraging on decaying animal and vegetable matter.

Common presenting symptoms include metallic taste acne 7 dpo cheap curatane online master card, vomiting skin care yang terbaik purchase curatane line, garlicky (or fishy) odour of breath skin care brand crossword buy curatane 5 mg without a prescription, intense thirst, burning epigastric pain, and diarrhoea. Massive focal myocardial injury with elevated serum levels of cardiac enzymes may occur. Section 3 indicative of the presence of phosphine in the breath, since silver nitrate is reduced to silver on exposure to it. The distillate is collected in an ice cold receiver containing 5 ml of 1% silver nitrate solution by dipping the adapter into it. Phosphine will blacken the silver nitrate paper, while hydrogen sulfide will blacken both papers. Though there is often intense thirst, do not administer water since whatever aluminium phosphide is still remaining in the stomach will react with it, releasing phosphine. While activated charcoal can be administered, it should be mixed with sorbitol (and not water), using 240 ml for every 30 grams. However, some authorities recommend the performance of gastric lavage as well as the administration of activated charcoal using aqueous solutions. While there were initial reports eulogising the efficacy of magnesium sulfate, particularly in relieving cardiovascular manifestations, later studies could not sustain such a view. Management of respiratory distress with 100% humidified oxygen, intubation, and assisted ventilation. Management of metabolic acidosis with sodium bicarbonate (50 mEq/15 min) until the arterial bicarbonate rises above 15 mmol/L. Magnesium sulfate therapy*: Magnesium sulfate is said to be beneficial in the management of cardiac arrhythmias. Forensic Issues Accidental and suicidal poisonings have been reported involving the consumption of rat pastes containing zinc phosphide. Contents of stomach are often haemorrhagic with mucosal shedding, and there is usually an intense garlicky odour. Chlorine Physical Appearance Chlorine is a greenish-yellow gas with a pungent odour. Chapter 8 Uses/Sources Non-Metallic Chemical Poisons Forensic Issues Prior to 1980, aluminium phosphide poisoning was virtually unreported in India. Today it is the leading cause of suicidal (and sometimes accidental) death in northern Indian states such as Punjab, Haryana, Uttar Pradesh, Madhya Pradesh, and Rajasthan. Southern states have so far not been significantly affected since aluminium phosphide is yet to make inroads into the agricultural sector here. But there are ominous indications of a gradual rise in the number of cases being reported. Instead, it is found as sodium chloride in land-locked lakes, as rock salt in underground deposits, in brines, and in natural deposits of sylvite and carnallite. Chlorine is used to manufacture a number of chemicals including solvents such as carbon tetrachloride, trichloroethylene, tetrachloroethylene, and methylene chloride, pesticides and herbicides, plastics, vinyl chloride, etc. It is also used in making refrigerants and propellants such as halocarbons and methyl chloride. Zinc Phosphide Physical Appearance Zinc phosphide is available as dark grey tetragonal crystals or crystalline powder marketed under various trade names (Agrophos, Commando, Sudarshan, Ratoff, Ratol, Robart, etc. Mode of Action, Clinical Features, Diagnosis,Treatment and Autopsy Features Same as for aluminium phosphide. Household bleach (5% sodium hypochlorite) when brought into contact with an acidic toilet bowl cleaner or drain cleaner will cause the release of chlorine gas. It is used extensively in pulpmills, where wood chips are processed into pulp as part of the paper manufacturing process. Chlorine is employed in purifying drinking and swimming water, for sanitation of industrial and sewage wastes and other disinfecting uses. It has been used as a poisonous gas for military purposes under the name bertholite. Chlorine is an irritant gas and inhalation provokes rhinorrhoea, lacrimation, coughing, chest pain, and shortness of breath. Major exposure results in laryngeal oedema, stridor, pneumonitis, and pulmonary oedema. In addition, the following features of systemic toxicity are seen: vomiting, vertigo, headache, ventricular ectopic beats, and metabolic acidosis.

Lymphadenopathy usually appears within 2 weeks of skin inoculation and may persist for months acne questionnaire discount curatane 5mg on line. In rare cases acne 30 years old male purchase 20 mg curatane amex, patients may develop complications such as encephalitis acne zapping machine discount 20mg curatane fast delivery, osteolytic lesions, hepatosplenic lesions, weight loss, prolonged fever, and fatigue. The differential diagnosis includes lymphogranuloma venereum, bacterial adenitis, sarcoidosis, infectious mononucleosis, tumors (benign or malignant), tuberculosis, tularemia, brucellosis, and histoplasmosis. Even in the presence of severe and multiple hepatic lesions, liver transaminase levels are normal and hepatomegaly is rare. In cases treated with antibiotics, a Jarisch-Herxheimer reaction may occur which manifests as fever, tachycardia, hyperventilation, hypotension, peripheral vasodilation, diffuse myalgias, and exacerbation of skin lesions. Management and Disposition the disease is usually self-limited and management is primarily symptomatic. Parents and patients should be reassured that the nodes are benign and frequently resolve within 2 to 4 months. Though the evidence is inconclusive, there appears to be a benefit to treating immunocompetent patients with 5 days of azithromycin. Other options include clarithromycin, trimethoprim-sulfamethoxazole, rifampin, or ciprofloxacin. Patients with hepatosplenic, neurologic, or neuroretinal disease should be treated with parenteral antibiotics (rifampin plus gentamicin or azithromycin). If the diagnosis is in doubt, serologic assays for Bartonella species can be sent. An erythematous, tender, suppurative node is seen in a young febrile patient with a history of cat scratch on the extremity. Cat-scratch disease is the most common cause of regional adenopathy and should be considered in all children or adolescents with persistent lymphadenopathy. Parinaud oculoglandular syndrome is characterized by a unilateral conjunctivitis and preauricular lymphadenopathy caused by B henselae. It results from a cellulitis of the epiglottis, aryepiglottic folds, and adjacent tissues. The patient generally appears toxic and prefers a sitting position, leaning forward with the neck extended in a sniffing position with an open mouth. With the addition of the H influenzae type B vaccine to the routine immunization schedule, there has been a dramatic decrease in the incidence of epiglottitis as well as a shift in the bacterial etiology. Adults typically have a more indolent course characterized by severe sore throat and odynophagia. On soft tissue lateral neck x-ray, the epiglottis is seen as rounded and blurred (thumbprint sign). Definitive diagnosis of epiglottitis requires direct visualization of a red, swollen epiglottis, preferably in an operating room with advanced airway measures readily available. Allow the child to remain undisturbed in a position of comfort while preparing for airway management. An agitated child is at increased risk for sudden, complete upper airway obstruction. If epiglottitis is suspected, the child should be allowed to remain in a position of comfort if they are maintaining an adequate airway. If possible, this should be done in the operating room or designated area where advanced airway management with sedation is available. An experienced anesthesiologist and surgeon should be readily available in case a surgical airway is necessary. Once the airway has been controlled, the patient should be sedated to avoid unplanned extubation. Lateral soft-tissue x-ray of the neck demonstrating thickening of aryepiglottic folds and thumbprint sign of epiglottis. Limitation of neck movement on examination, especially with hyperextension, or torticollis will often be seen. The characteristic retropharyngeal edema is a result of cellulitis and suppurative adenitis of the lymph nodes located in the prevertebral fascia. It is seen on a soft tissue lateral x-ray of the neck as prevertebral soft tissue thickening. The differential diagnosis includes pharyngitis, acute laryngotracheobronchitis, epiglottitis, membranous (bacterial) tracheitis, cervical adenitis, infectious mononucleosis, peritonsillar abscess, foreignbody aspiration, and diphtheria.

After centrifugation skin care 15 days before marriage cheap curatane 10mg amex, which concentrates the parasitized cells around the float skin care natural tips cheap 5 mg curatane with visa, fluorescence microscopy is performed acne face mask best curatane 10mg. Microtube concentration methods with acridine orange staining Malaria cannot be diagnosed clinically with accuracy, but treatment should be started on clinical grounds if the laboratory confirmation is likely to be delayed. In areas of the world where malaria is endemic and transmission is high, low-level asymptomatic parasitemia is common in otherwise-healthy people. Antibody and polymerase chain reaction tests have no role in the diagnosis of malaria. At any level of parasitemia, the finding that >50% of parasites are tiny rings (cytoplasm width less than half of nucleus width) carries a relatively good prognosis. A rectal formulation of artesunate has been developed as a community-based prereferral treatment for patients in the rural tropics who cannot take oral medications. Although the artemisinin compounds are safer than quinine and considerably safer than quinidine, only one formulation is available in the United States. The antiarrhythmic quinidine gluconate is as effective as quinine and, as it is more readily available, has replaced quinine for the treatment of malaria in the United States. Severe falciparum malaria constitutes a medical emergency requiring intensive nursing care and careful management. The patient should be weighed and, if comatose, placed on his or her side or prone. Ancillary drugs such as high-dose glucocorticoids, urea, heparin, dextran, desferrioxamine, antibody to tumor necrosis factor, and high-dose phenobarbital (20 mg/kg) have proved either ineffective or harmful in clinical trials and should not be used. In acute renal failure or severe metabolic acidosis, hemofiltration or hemodialysis should be started as early as possible. If artemether, quinine, or quinidine is used, an initial loading dose must be given so that therapeutic concentrations are reached as soon as possible. If there is any doubt about the resistance status of the infecting organism, it should be considered resistant. Antimalarial susceptibility testing can be performed but is not generally available and yields results too slowly to influence the choice of treatment. Several drugs are available for oral treatment, and the choice of drug depends on the likely sensitivity of the infecting parasites. In endemic areas, the World Health Organization now recommends artemisinin-based combinations as first-line treatment for uncomplicated falciparum malaria everywhere. These rapidly and reliably effective drugs are often unavailable in temperate countries (including the United States), where treatment recommendations are limited by the registered available drugs. Clindamycin (10 mg/kg bid for 7 days) or Atovaquone-proguanil (20/8 mg/kg qd for 3 days with food) Sensitive P. The data from large studies in Southeast Asia showed a 35% reduction in mortality rate from that with quinine. Severe malaria in children in high-transmission settings has different characteristics; thus trials are ongoing in Africa comparing artesunate with quinine to determine whether there is a survival benefit in African children. If one of the artemisinin derivatives is given, dose reductions are unnecessary, even in renal failure. Exchange transfusion should be considered for severely ill patients, although the precise indications for this procedure have not been agreed upon. It has been recommended that-if safe and feasible-exchange should be considered for patients with severe malaria, but there is no clear evidence that this measure is beneficial. If respiratory support is not available, then a full loading dose of phenobarbital (20 mg/kg) to prevent convulsions should not be given as it may cause respiratory arrest. Anemia develops rapidly; if the hematocrit falls to <20%, then whole blood (preferably fresh) or packed cells should be transfused slowly, with careful attention to circulatory status. Children presenting with severe anemia and acidotic breathing are often hypovolemic; in this situation, resuscitation with crystalloids or blood is indicated. Management of fluid balance is difficult in severe malaria, particularly in adults, because of the thin dividing line between overhydration (leading to pulmonary edema) and underhydration (contributing to renal impairment). If necessary, central venous pressures should be measured and maintained in the low-normal range.

It is important to note that in some cases acne adapalene cream 01 curatane 10 mg otc, there may be no clear fang marks skin care for eczema discount curatane 20mg mastercard, but a vague scratch mark skin care anti aging curatane 20 mg on line, and yet serious poisoning may occur. Myoglobinaemia and myoglobinuria occur, resulting in acute tubular necrosis and renal failure. In some cases, paralysis of respiratory muscles causes death due to respiratory failure. This is highly sensitive, but specificity may be inadequate to distinguish between different species of snakes. Immobilisation: Since exertion can enhance systemic absorption of venom, there is universal consensus that the patient should be put at rest, and the bitten extremity immobilised by using a splint or sling. A firm rubber pad is applied with cotton bandaging over the site of the bite and the limb is then immobilised with a splint. However, there may be an increased risk of local tissue necrosis, bruising and pain at the site, which should be evaluated over the potential risk of systemic envenomation. Beverages: Use of "stimulating" beverages such as coffee is inadvisable and ineffective. In some cases, it can provoke vomiting, the tendency for which is usually present in the early hours following a bite. But there are serious risks associated with tourniquets and other similar occlusive methods, which include ischaemia and gangrene, damage to peripheral nerves (especially lateral popliteal nerve), increased fibrinolytic activity, congestion, swelling, increased bleeding, and increased local effect of venom. It has also been claimed that subsequent release of a tourniquet which has been retained for some time, leads to a flooding of Treatment of Snakebite 1. Because of the dangers associated with it, today the general consensus is against application of a tourniquet. Incision and suction: There is much controversy surrounding the issue of incision and suction as a first-aid measure for snakebite. While there have been staunch advocates especially in the past, the current view is generally against such a practice. Some investigators have claimed that effective incision and suctioning (by breast pump or syringe) for a 30 minute period can extract about 90% of venom, even when done as long as 2 hours after the bite. However, some others vehemently deny this, and say that such a procedure can remove only about 20% of injected venom at the most. Today, most authorities strongly condemn incision and suction as useless and hazardous. But some practitioners still advocate the method in selected cases, especially if it is done within the first 5 to 10 minutes following the bite. Parallel incisions may be made through the fang marks, about 1 cm long and no deeper than 3 mm, in the long axis of the limb. Cyrotherapy: Local cooling (application of ice) in the region of the bitesite was previously recommended for minimising the absorption of venom. Today this is universally condemned because of serious risk of necrosis leading to gangrene, which may even necessitate amputation. Electric shock: It has been suggested that if snake antivenom is not available to treat a venomous bite, local electric treatment may be done which is claimed to be life saving. The electric shock (25 kv, 1 ma) is to be applied direct to the bite by means of an insulated probe for a couple of seconds, and repeated 4 to 5 times at 5 to 10 second intervals, taking care to ground the area as closely to the site of the bite as possible. If pain is severe, several authorities recommend judicious use of narcotic analgesics such as pentazocine or pethidine, even though in some cases this can be hazardous. Aspirin and non-steroidal anti-inflammatory drugs must not be used, since they commonly cause gastric erosions, and could lead to persistent gastric bleeding in patients with incoagulable blood, as in the case of viper bites. Intramuscular and subcutaneous injections should be avoided, especially in patients with incoagulable blood, since they can lead to haematoma formation. If the patient has not been previously immunised, tetanus antiserum or tetanus human globulin must be given.

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